Provider Demographics
NPI:1891792883
Name:MORRIS, TROY DALE (MD)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:DALE
Last Name:MORRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 PHYSICIANS LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6102
Mailing Address - Country:US
Mailing Address - Phone:662-393-7722
Mailing Address - Fax:662-393-7756
Practice Address - Street 1:75 PHYSICIANS LN
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6102
Practice Address - Country:US
Practice Address - Phone:662-393-7722
Practice Address - Fax:662-393-7756
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS080001735Medicare ID - Type Unspecified
B30366Medicare UPIN